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INVESTIGATING
INVESTIGATIONS

to advance the
State-of-the-Art of
investigations, through
investigation process
research.



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Launched Aug 26 1996.

 

 

Research Report

 

INVESTIGATION RESEARCH PROJECT LISTING
Posted 4 Dec 96- no further update on results

COMMONWEALTH OF AUSTRALIA

COMMONWEALTH OF AUSTRALIA

DEPARTMENT OF TRANSPORT AND REGIONAL DEVELOPMENT

BUREAU OF AIR SAFETY INVESTIGATION

CENTRAL OFFICE

24 Mort Street Telephone : 06 2746456
Braddon ACT 2601 Telex : AA62591
AUSTRALIA Fax : 06 2473117
Postal Address : P O Box 967
: Civic Square
: ACT 2608
: AUSTRALIA

15 October 1996

Dear Mr Benner,

I refer to your Internet query on research by BASI into investigation processes and offer the following for your consideration.

Over a period of several years, BASI considered how it could be best served in conducting investigations into aircraft accidents and incidents. The Bureau concluded that several changes were necessary and has since implemented those changes to enhance its modus operandi.

Firstly, the introduction of categorising occurrences (accidents and incidents) was designed to enable appropriate effort to be devoted to events which would give us a positive safety outcome. We categorise occurrences from Category 1 (the `worst') to Category 5 (assessed as having the least safety benefit) and ensure that resources and time are managed accordingly. On many occasions, incidents are given a higher priority or categorisation than some accidents. All investigations consider potential systemic issues or latent failures, as well as the more obvious active failures.

Secondly, employment of six specialist investigator types has given BASI the flexibility and expertise to carry out in-depth systemic investigations of a range of occurrences. The types include operations (pilots), air traffic services, engineers, human performance, maintenance (licensed aircraft maintenance engineers), and technicians (eg electronics, communications etc). All BASI air safety investigators carry out a formal Australian university-accredited aircraft accident investigation training course early in their Bureau career, so each investigator is appropriately trained. The course is heavily slanted towards Australian requirements, offering a significant advantage over similar courses overseas. It also ensures that each specialist knows something about what the rest of the Bureau investigation team may be doing.

Next, the introduction of a confidential aviation incident reporting (CAIR) system has provided an avenue for aviation industry members to advise BASI of areas of safety concern. Until this system was introduced, many problems and deficiencies remained unnoticed, unknown, or unreported.

Another result of Bureau research was confirmation of the value of a regular journal produced by the nation's investigative authority. Our quarterly magazine, Asia Pacific Air Safety, is a key element in our ability to communicate safety concerns throughout the region. The magazine does not compete with any publications produced by the regulator, the Civil Aviation Safety Authority, and in fact has the support of the regulator.

Finally, the establishment of a Safety Analysis Branch was designed to ensure that well researched recommendations were made. It also enables us to examine underlying latent deficiencies in the aviation system, both before and after aircraft occurrences.

The combined effect of these initiatives has been to ensure that BASI remains an accepted and respected authority throughout the aviation industry. Whilst we do not have any active program of investigation research in place at present, our techniques are subject to constant self-examination and scrutiny intended to ensure we are able to respond appropriately to any foreseeable situation.

I hope this information proves useful.

Yours sincerely,

Lindsay Naylor Manager Investigations
for Director

Contact : Lindsay Naylor or Webmaster with comments